Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

Thursday, September 05, 2013

Study Explains Errors Caused by EHR Default Values - With Only Four Reports of "Temporary" (By the Grace of God) Patient Harm

A new study analyzes errors related to
“default values” which are standardized medication order sets in
electronic health records and computerized physician order entry
systems.

The Pennsylvania Patient Safety Authority, an independent state
agency, conducted the study. “Default values are often used to add
standardization and efficiency to hospital information systems,” says
Erin Sparnon, an analyst with the authority and study author. “For
example, a healthy patient using a pain medication after surgery would
receive a certain medication, dose and delivery of the medication
already preset by the health care facility within the EHR system for
that type of surgery.”

These presets are the default value, but safety issues can arise if
the defaults are not appropriately used. Sparnon studied 324 verified
safety reports, noting that 314, or 97 percent, resulted in no harm. Six
others were reported as unsafe conditions that caused no harm and four
reports caused temporary harm involving some level of intervention.

One might ask: how many unreported or yet-to-be-reported EHR/CPOE cases involved, or will involve, permanent harm?

Regarding the "temporary harms", one which includes "default times" as opposed to doses:

The four cases requiring intervention involved accepting a default
dose of a muscle relaxant that was higher than the intended dose, giving
an extra dose of morphine[keep playing with 'extra doses' of drugs like morphine enough, and you're going to kill someone - ed.] because of an accepted default administration
time that was too soon after the last dose, having a patient’s
temperature spike after a default stop time automatically cancelled an
antibiotic[do this enough, and you're going to get sepsis and septic shock to deal with - ed.] and rising sodium levels in a patient because confused
wording made nurses believe that respiratory therapy was administering
an ordered antidiuretic.[Apparently the 'default'- ed.]

More on the errors:

The most common types of errors in the study were wrong time (200),
wrong dose (71) and inappropriate use of an automated stopping function
(28).

Any of these, especially the latter two, could have caused harm depending on degree...and to those Risk Management majors out there, eventually will.

“Many of these reports also showed a source of erroneous data and
the three most commonly reported sources were failure to change a
default value, user-entered values being overwritten by the system and
failure to completely enter information which caused the system to
insert information into blank parameters,” Sparnon says.

Hence my claim that the term
"EHR" is anachronistic, and that these systems now are really
cybernetic command-and-control mediators and regulators of care (via cybernetic proxy).

“There were
also nine reports that showed a default needed to be updated to match
current clinical practice.”

The need for a constant, rigorous updating process (which will in the real world likely always be 'behind'), among many others, is a factor that makes the idealistic belief/promise that "health IT will save money and increase safety" (let alone "revolutionize" medicine) unpersuasive.

And this, at the same time that the The HIT Policy Committee, a body of industry stakeholders who advise federal officials, on Sept. 4 adopted final recommendations on health IT risk consistent with an attitude of health IT exceptionalism that included:

"HIT should not be subject to FDA [or any - ed.] premarket requirements" and "Vendors should be required to list products which are considered to
represent at least some risk if a non-burdensome approach can be
identified."

If not, no list? ... And what, exactly, is a "non-burdensome" approach, one might ask?

Perhaps the penalty for health IT hyperenthusiasts**, short of the Biblical penalty of one of their loved ones suffering the fate of a guinea pig in a medical experiment, should be to be compelled to
fly some third rate air carrier with a safety record of "we only had a
few near-crashes last month."

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